POSTOPERATIVE SYNERGISTIC GANGRENE ON THE ANTERIOR ABDOMINAL WALL – REPORT OF A CASE

Continental J. Tropical Medicine 4: 23 - 26, 2010 ISSN: 2141 - 4167

© Wilolud Journals, 2010 http://www.wiloludjournal.com

POSTOPERATIVE SYNERGISTIC GANGRENE ON THE ANTERIOR ABDOMINAL WALL - REPORT

OF A CASE

Afeyodion Akhator, Emmanuel A. Sule, Emmanuel E. Akpo
Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State

University, Abraka, Nigeria

ABSTRACT

The management of a 23 year old boy who postoperatively developed severe anterior abdominal wall
infection diagnosed as postoperative synergistic gangrene (Meleney disease) following laparotomy for
penetrating abdominal injury is presented. The patient was managed with early aggressive debridement
in the theatre, repeated bedside debridement over several weeks and intravenous antibiotics. His wound
healed by secondary intention and he was discharged after 46 days on admission.

KEYWORDS: postoperative synergistic gangrene, bedside debridement

INTRODUCTION

Postoperative synergistic gangrene is a rare rapidly spreading and relentless destructive subcutaneous lesion first
described by Meleney as post operative synergistic gangrene in 1931 (Meleney, 1931). A variety of terms has
been used to describe this condition including necrotizing fasciitis, progressive synergistic bacterial gangrene,
and hospital gangrene (Wilson, 1952; Gannon, 1994). Differentiation from cellulitis and abscesses is important
but difficult in the early phase because of paucity of early signs, and is usually diagnosed because the disease
continued to progress in spite of therapy (Wong et al, 2003).

The infection usually dissects along fascial planes with extensive necrosis of the fascia and undermining of the
surrounding structures. Skin gangrene is due to thrombosis of the nutrient vessels. The disease lies as a clinical
entity between cellulitis and myonecrosis with aggressive necrosis of skin and fascia while sparing muscle
(Goldberg et al 1984). Mortality has been reported to be 21.3% from Singapore and 50% in Ilorin, Nigeria
(Wong et al 2003; Adigun & Abdulrahaman, 2004).

The incidence of necrotizing fasciitis has been on the increase because of increase of immuno suppressed patient
with diabetes mellitus, cancer, alcoholism and HIV (Sharkawy et al 2004). A case of postoperative gangrene in a
previously healthy young man is presented and the challenges we had in managing him is discussed.

CASE REPORT

A 23 year old boy was referred to our center on account of spreading infection in his operative wound. He was
involved in an inter-tribal clash and sustained an extensive laceration in the left hypochondrial region from a
cutlass. He had immediate laparotomy in the referral center where repair of small bowel laceration was done. On
the fourth day post surgery the wound was noticed to be draining brownish fluid and the skin sutures were
removed. Two days later, extensive bullae were noticed in the anterior abdominal wall and he was then referred.
On examination, the patient was febrile temperature of 38.4 degree Centigrade, tachypnoiec with a respiratory
rate of 32 cycles/min with tachycardia of 104/min. Examination of the abdomen showed a transverse left
hypochondrial wound and a midline wound without skin sutures with extensive bullae of the skin of the anterior
abdominal wall. Both the wounds and bullae were draining brownish foul smelling fluid (Figures 1 & 2).

Investigations done showed a white cell count of 15,700 cells with 92% neutrophils. Packed cell volume was
23%. Electrolytes, urea and creatinine were within normal limits. Urinalysis showed no abnormality. Culture of
the wound showed mixed growth of streptococcus and coliform organism. Abdominal ultrasound did not show
any intraperitoneal fluid collection or abscesses and plain abdominal X-rays were normal. He was assessed has
having postoperative synergistic gangrene.

He was commenced on intravenous fluids - Ringers lactate alternating with 5% dextrose water 3 liters a day,
intravenous ceftriaxone 1 gram 12 hourly and metronidazole 500mg 8 hourly. He was transfused with 3 units of
blood. He underwent a wound debridement in theatre. It was noticed that there was extensive fascia involvement
beneath the skin. All bullae and dead fascia were excised; wound was irrigated with copious saline and dressed.
Daily saline dressing was continued and bedside debridement was done four times over the following three
weeks. Figure 3 shows appearance of wound after 3 weeks of treatment.

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Afeyodion Akhator et al.,: Continental J. Tropical Medicine 4: 23 - 26, 2010

The patient's condition improved and wound healed by secondary intention (Figures 4 & 5). He was discharged
home on the 46 th day of admission.

DISCUSSION

Postoperative synergistic gangrene is a deadly form of soft tissue infection that has been tagged "Meleney's
Minefield" (Wong et al, 2006). It has a mortality rate of 34% (range of 6%-76%). Survival depends on early
recognition and prompt aggressive debridement along with targeted antibiotic therapy.

Most patients with postoperative synergistic gangrene had pre existing immunosuppressive condition such as
diabetes mellitus, chronic renal failure and HIV or are elderly or obese. Our patient was a healthy young man
who had not used any hard drugs and the only identifiable risk factor was surgery as reported in 4.5% of cases
(Wong et al 2003).

Diagnosis of postoperative synergistic gangrene is difficult due to paucity of early cutaneous signs. In the review
by Wong et al 2003, only 14.6% of their 89 patients were diagnosed at the time of admission (Wong et al, 2003).
They gave an excellent guide for making early diagnosis of this condition. Diagnosis in this patient was made
because of the presence of characteristic bullae in the anterior abdominal wall. Subsequent full-thickness skin
and superficial fascia necrosis sparing underlying muscle differentiated it from a clostridial myonecrosis.
Invading organisms were identified from culture of wound swab. Although culture of wound biopsies could not
be done for logistic reasons, culture of wound biopsies taken from the spreading periphery of the necrotizing
infection gives higher yield. Associated systemic conditions including diabetes mellitus, HIV were ruled out in
this case as non-recognition and management of systemic comorbdities may prove inimical to success. The
diagnosis was confirmed intra-operative by the presence of foul smelling and dirty serous fluid, pus and grayish
necrotic fascia. Other significant findings were the loss of resistance of the deep fascia to blunt dissection and
lack of bleeding of the fascia during dissection as described in the literature (Akhtar et al, 2010). Plain
abdominal xray and abdominal ultrasound showed negative findings. However computerized tomography scan
and MRI have been reported to aid early diagnosis (Wyoskki et al 1998, Schmid et al 1997) but their use should
never delay operative intervention (Wong et al 2003). A high index of clinical suspicion is thus required for
early diagnosis and intervention.

The management of postoperative synergistic gangrene is aggressive resuscitation, surgical debridement with
excision of all dead tissues and targeted elaboration of broad spectrum antibiotics (Adigun and Abdulrahaman
2004). A second look within 24 and 48hrs should be done to assess the need for serial debridement; (Wong et al
2003) as occurred in our case. Due to limited financial resources, our case had subsequent serial debridement by
bedside under some analgesia. The resultant skin defects contracted adequately and were allowed to heal by
secondary intention. Skin grafts/flaps are recommended to cover the extensive defects resulting from
debridement, but the financial constraint in this patient precluded skin graft (Adigun and Abdulrahaman 2004).
The use of negative pressure wound therapy and hyperbaric oxygen therapy in the management of these patients
have been reported to improve survival and shorten treatment times (Phelps et al, 2006). These modalities are
not available in resource limited countries. Therefore management should be based on early recognition, early
surgical debridement and broad spectrum antibiotic therapy.

CONCLUSION

We recommend a high index of suspicion for postoperative synergistic wound infection and early radical
debridement of suspicious postoperative wound. Repeated debridement can be done safely by the bedside of the
patient, thereby reducing overall cost in the treatment of these patients.

REFERENCES

Adigun Al, Abdulrahaman LO (2004). Necrotizing fasciitis in a plastic surgical unit: a report of 10 patients from
Ilorin. Nigerian Journal of Surgical Research; 6(1-2): 21-24.

Akhtar M, Akhtar F, Bandyopadhyay D, Montgomery H, & Mahomed A (2010). Abdominal Wall Necrotizing
Fasciitis: A Survivor from "Meleney's Minefield". The Internet Journal of Surgery; 22(1)

Gannon T (1994). Dermatologic emergencies. Postgrad Med;96(l):67-82.

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Afeyodion Akhator et al.,: Continental J. Tropical Medicine 4: 23 - 26, 2010

Goldberg GN,Hansen RC, Lynch PJ (1984). Necrotising fasciitis in infancy; Report of three cases and review of
the literature. . Paediatric Dermatology ;2:55-63.

Meleney F.L (1933). A differential diagnosis between certain types of infective gangrene of skin. Surgery,
Gynecology and Obstectrics; 56: 847-867.

Phelps JR, Fagan R, Pirela-Cruz MA (2006). A case study of negative pressure wound therapy to manage acute
necrotizing fasciitis. Osteotomy Wound Management; 52(3): 54-59.

Schmid MR, Kossmann T, Due well S (1998). Differentiation of necrotizing fasciitis and cellulitis using MR
imaging. AJR AMm J Roentgenol; 170:6 15-20.

Sharkawy A, Low DE, Saginur R, et al. Severe group A streptococcal soft tissue infections in Ontario: 1992-
1996. Clinical Infectious Disease 2002;34:454-60.

Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, & Low CO (2003). Necrotizing Fasciitis: Clinical
Presentation, Microbiology, and Determinants of Mortality. The Journal of Bone & Joint Surgery; 85-A(8):
1454-1460.

Wong CH, Song C, Ong YS, Tan BK, Tan KC, Foo CL (2006). Abdominal wall necrotizing fasciitis: it is still
"Meleney's minefield". Plast Reconstr Surg; 117(7): 147-150.

Wyoski MG, Santora TA, Shah RM, Friedman AC (1997). Necrotising fasciitis; CT characteristics.
Radiology ;203: 859-63.

Figure 1 - Appearance at presentation 1

Figure 2 - Appearance at presentation 2

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Figure 3 - Appearance at 3 week of treatment Figure 4 - Appearance at discharge 1

Figure 5 - Appearance at discharge 2

Received for Publication: 28/10/2010
Accepted for Publication: 09/11/2010

Corresponding Author

A. Akhator

Department of Surgery, Faculty of Clinical Medicine, College of Health Sciences, Delta State University, PMB

1 , Abraka, Nigeria.

EMAIL: doc_akhator@yahoo.com

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